rDVM Referral Form Emergency Treatment Referral FormDulles South Animal Emergency and Referral Hospital will accept patient transfers between the hours of 6 am-midnight. Please complete this form so we have an understanding of any diagnostics that have been done, as well as the intended treatment plan. If needed, our veterinarian will contact you to discuss the case and plan.Once a patient is transferred, our veterinarian will assess and amend the treatment plan as necessary to provide the standard of care. After midnight, our veterinary technicians and support staff will provide direct care for the patients under the direction of a veterinarian on call. There may be some circumstances where the condition of the patient necessitates intervention by a criticalist or other specialist, in which case our veterinarians will discuss recommendations with the owner and amend the plan as needed.rDVM INFORMATIONHospital Name:Referring Veterinarian:Hospital Phone:Fax:Email: Preferred method to update you on case:PhoneFaxEmailBest Time to Call: : HH MM AMPM CLIENT INFORMATIONClient Name: First Last Home Phone:Cell Phone:PATIENT INFORMATIONPatient Name: First Last Species/Breed:Age:Weight:Vaccinations Current?YesNoSex:MaleMale - neuteredFemaleFemale - spayedPATIENT MEDICAL INFORMATIONCondition of Patient:HealthyStableCriticalMoribundAllergies?Presenting Problems/Diagnosis:DiagnosticResults/Treatments/Medications:Concerns/Requests:For the following services, please call to schedule an appointment.Surgery Services ReferralDIAGNOSTIC INFORMATIONAnesthetic risk classification if known?Allergies/medication Reactions?DiagnosticResults/Treatments/Medications:Service Requests:Post-Op Requests:Cold Laser TherapyMonitoring overnight & transfer back to rDVMTotal Post-Op care (including follow up visits)Outpatient Surgery OnlySurgery Consultation OnlyRehabilitation Services ReferralDIAGNOSTIC INFORMATIONAre there any cardiac concerns?Allergies?PresentingProblems/Diagnosis:DiagnosticResults/Treatments/Medications:Service Requests: Evaluate and Treat – May include PROM, TENS unit, Cryo/Thermal therapy, therapeutic exercises, underwater treadmill, and home therapy development. Underwater Treadmill Only - Wellness/weight loss/conditioning.DOCUMENTS & RECORDSCheck all that apply: Medical Records/Diagnostic Results Attached Medications sent with patient Radiographs sent with patient Radiographs AttachedPlease submit pertinent medical records and information about the pet’s medical condition, if available.
